Pelvic lymphadenectomy for cervical carcinoma: Laparotomy extraperitoneal, transperitoneal or laparoscopic approach? A randomized study

Robot-Assisted versus Laparoscopic Surgery for Pelvic Lymph Node Dissection in Patients with Gynecologic Malignancies

Objectives

The objective of this study was to compare the surgical outcomes for pelvic lymph node dissection (PLND) performed through conventional laparoscopic surgery (CLS) versus robot-assisted surgery (RAS) in patients with gynecologic malignancies.

Materials and Methods

Perioperative data, including operative time, estimated blood loss, and complications, were retrospectively analyzed in 731 patients with gynecologic malignancies who underwent transperitoneal PLND, including 460 and 271 in the CLS and RAS groups, respectively. Data were statistically analyzed using the Chi-square test or Student's t-test as appropriate. P < 0.05 was considered statistically significant.

Results

The mean age was 50 ± 14 years and 53 ± 13 years in the RAS and CLS groups (P < 0.01), respectively. The mean body mass index was 23.4 ± 4.8 kg/m2 and 22.4 ± 3.6 kg/m2 in the RAS group and CLS groups (P < 0.01), respectively. The operative time, blood loss, and number of resected lymph nodes were 52 ± 15 min, 110 ± 88 mL, and 45 ± 17, respectively, in the RAS group and 46 ± 15 min, 89 ± 78 mL, and 38 ± 16, respectively, in the CLS group (all P < 0.01). The rate of Clavien-Dindo Grade ≥ III complications was 6.3% and 8.7% in the RAS and CLS groups, respectively (P = 0.17).

Conclusion

Shorter operative time and lower blood loss are achieved when PLND for gynecologic malignancies is performed through CLS rather than RAS. However, RAS results in the resection of a greater number of pelvic lymph nodes.

Laparoscopic Versus Abdominal Radical Hysterectomy for Cervical Cancer: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopic radical hysterectomy (LRH) and open abdominal radical hysterectomy (ARH) have been used for cervical cancer treatment. We aimed to perform a meta-analysis to compare the efficacy and safety of LRH and ARH in the treatment of cervical cancer to provide reliable evidence to the clinical cervical cancer treatment.

METHODS

Two investigators independently searched PubMed and other databases for randomized controlled trials (RCTs) comparing LRH and ARH for cervical cancer treatment up to May 31, 2022. The risk of bias assessment tool recommended by Cochrane library was used for quality assessment. RevMan 5.3 software was used for meta-analysis.

RESULTS

Fourteen RCTs with a total of 1700 patients with cervical cancer were finally included. Meta-analyses indicated that compared with ARH, LRH reduced the intraoperative blood loss (mean difference [MD]=-58.08; 95% CI, -70.91, -45.24), the time to first passage of flatus (MD=-14.50; 95% CI, -16.55, -12.44) (all P <0.05), and increase the number of lymph nodes removed (MD=3.47; 95% CI, 0.51, 6.43; P =0.02). There were no significant differences in the duration of surgery (MD=27.62; 95% CI, -6.26, 61.49), intraoperative complications (odd ratio [OR]=1.10; 95% CI, 0.17, 7.32), postoperative complications (OR=0.78; 95% CI, 0.33, 1.86), relapse rate (OR=1.45; 95% CI, 0.56, 3.74), and survival rate (OR=0.75; 95% CI, 0.52, 1.08) between LRH group and ARH group (all P >0.05).

CONCLUSIONS

LRH has more advantages over ARH in the treatment of cervical cancer. Still, the long-term effects and safety of LRH and ARH need more high-quality, large-sample RCTs to be further verified.

Incidence and risk of venous thromboembolism according to primary treatment type in women with endometrial cancer: a population-based study

Background

Current prophylaxes and treatments for venous thromboembolism (VTE) in women with gynecologic cancer are mainly guided by studies on solid cancers because studies in gynecologic cancer did not provide sufficient data. Large-scale studies evaluating the incidence and risk of VTE according to therapeutic modality may guide prophylaxis and treatment of VTE in gynecologic cancer. This study was performed to determine the incidence and risk of VTE according to primary treatment type in Korean women with endometrial cancer.

Methods

We selected 26,256 women newly diagnosed with endometrial cancer between 2009 and 2018 from the Korean Health Insurance Review and Assessment Service database. During the total follow-up period and first six months after primary treatments initiation, the incidence and risk of VTE were evaluated according to primary treatment type, that is, no treatment, surgery, radiotherapy, chemotherapy, or hormone therapy.

Results

VTE occurred in 136 per 10,000 women during the total follow-up period and in 54 per 10,000 women during the first six months with the highest frequency in women that underwent chemotherapy. During the first year, the monthly incidence of VTE decreased with time among women that underwent no treatment, surgery, or hormone therapy and remained unchanged in those that received radiotherapy or chemotherapy. Compared with women that received no treatment, VTE risk, especially of PE significantly increased in women that underwent chemotherapy (VTE: hazard ratio (HR), 2.334; 95% CI, 1.38–3.949; P = 0.002) (PE: HR, 2.742; 95% CI, 1.424–5.278; P = 0.003) or hormone therapy (VTE: HR, 2.073; 95% CI, 1.356–3.17; P = 0.001) (PE: HR, 2.086; 95% CI, 1.19–3.657; P = 0.01) during the total follow-up period and women that underwent only chemotherapy during the first six months (VTE: HR, 2.532; 95% CI, 1.291–4.966; P = 0.007) (PE: HR, 3.366; 95% CI, 1.496–7.576; P = 0.003).

Conclusions

In this cohort study, the incidence and risk of VTE were highest in women with endometrial cancer that underwent chemotherapy as a primary treatment. Notably, the incidence of VTE decreased over time in women that received no treatment, surgery, or hormone therapy. This study can help guide therapies for prophylaxis and treatment of VTE in women with endometrial cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08853-x.

Incidence and risk of venous thromboembolism according to primary treatment in women with ovarian cancer: A retrospective cohort study

Objective

This study aimed to investigate incidence and risk for venous thromboembolism (VTE) according to primary treatment in women with ovarian cancer.

Methods

We selected 26,863 women newly diagnosed with ovarian cancer between 2009 and 2018 from the Korean Health Insurance Review and Assessment Service databases. During the total follow-up period and the first six months after initiation of primary treatments, incidence and risk of VTE were evaluated according to primary treatment as no treatment, surgery, radiotherapy, or chemotherapy.

Results

The mean follow-up period was 1285.5±6 days. The VTE incidence was highest in women who underwent chemotherapy (306 per 10,000 women). Among women who underwent surgery, VTE was highest in surgery with neoadjuvant chemotherapy (536 per 10,000 women), followed by surgery with adjuvant chemotherapy (360 per 10,000 women) and surgery alone (132 per 10,000 women). During the first 12 months, monthly incidence of VTE decreased. Compared with women with no treatment, risk of VTE significantly increased in women undergoing chemotherapy (HR 1.297; 95% CI, 1.08–1.557; P = 0.005) during the total follow-up period and decreased in women undergoing surgery (HR 0.557; 95% CI, 0.401–0.775; P<0.001) and radiotherapy (HR 0.289; 95% CI, 0.119–0.701; P = 0.006) during the first six months. Among women who underwent surgery, VTE risk significantly increased in surgery with neoadjuvant chemotherapy (HR 4.848; 95% CI, 1.86–12.632; P = 0.001) followed by surgery with adjuvant chemotherapy (HR 2.807; 95% CI, 1.757–4.485; P<0.001) compared with surgery alone during the total follow-up period and in surgery with neoadjuvant chemotherapy (HR 4.223; 95% CI, 1.37–13.022; P = 0.012) during the first six months.

Conclusions

In this large Korean cohort study, incidence and risk of VTE were highest in women with ovarian cancer who underwent chemotherapy and surgery with neoadjuvant chemotherapy as a primary cancer treatment. Incidence of VTE decreased over time.

Incidence and risk factors of VTE in patients with cervical cancer using the Korean national health insurance data

This study investigated incidence and risk factors for venous thromboembolism (VTE) in patients with cervical cancer. We selected 49,514 patients newly diagnosed with cervical cancer from the Korean Health Insurance Review and Assessment Service databases. During the total follow-up period and first 6 months after initiation of primary treatments, incidence of VTE, and association of risk factors with VTE occurrence were evaluated according to primary treatments or no treatment, surgery, radiotherapy, and chemotherapy. VTE occurred in 1.15% of patients with cervical cancer. Regardless of the period after initiation of primary treatments, and of VTE, the incidence of thromboembolism was highest in chemotherapy. During the first 12 months, monthly incidence of VTE was highest in chemotherapy and decreased with time in all primary treatments. Compared with no treatment, VTE risk significantly increased for all primary treatments (surgery: HR 1.492; 95% CI 1.186-1.877) (radiotherapy: HR 2.275; 95% CI 1.813-2.855) (chemotherapy: HR 4.378; 95% CI 3.095-6.193) and for chemotherapy during the first 6 months (HR 3.394; 95% CI 2.062-5.588). In this cohort study, incidence and risk of VTE in patients with cervical cancer were the highest when chemotherapy was the primary cancer treatment, and incidence of VTE decreased with time.

Strategies for the Treatment of Cervical Cancer with Bulky Pelvic Lymph Nodes: An Overview of the Current Evidence

Cervical cancer commonly metastasizes first to the pelvic lymph nodes and then subsequently spreads to distant organs, making lymph node metastases the most significant prognostic factor in cervical cancer, and the strategy for its treatment directly influences prognosis. This review focuses on the treatment strategies for cases of cervical cancer with bulky pelvic lymph nodes. Concurrent chemoradiotherapy is the standard treatment modality for patients with pelvic lymph node metastases, but it is inadequate for bulky pelvic lymph nodes. Accordingly, surgical resection of the bulky lymph nodes has been attempted, and its therapeutic significance has been reported. If the bulky lymph nodes are unresectable, definitive concurrent chemoradiotherapy is performed. If it yields an inadequate degree of lymph node shrinkage, boosted radiation should be considered. The addition of chemotherapy after concurrent chemoradiotherapy has also been reported to be effective in patients with lymph node metastases and is currently being evaluated in clinical trials.

External Iliac Artery Injury and Thrombosis during Laparoscopic Gynecologic Surgery

Although vascular injury during laparoscopic surgery is rare, it is occasionally reported. Previously, several physicians have reported cases of compartment syndrome resulting from a thrombus during gynecologic surgery. However, few reports describe thrombosis occurring in artery vessels as a result of applying angiopressure. Herein, we report the case of a 53-year-old woman with endometrioid carcinoma and a vascular injury that resulted in thrombus formation; this is the first such case to be reported. The complication was successfully treated by means of direct anastomosis following partial resection of the injured iliac artery. This is the first report of a case in which applying angiopressure for a vascular injury during laparoscopic pelvic lymphadenectomy led to an intra-arterial thrombus which was found and treated without sequelae.

Number of paraaortic lymph node dissections as a prognostic factor in locally advanced cervical cancer

BACKGROUND

Lymph node (LN) metastases are the most important prognostic factor in locally advanced cervical cancer. Paraaortic lymphadenectomy is the only method able to confirm the presence of metastasis and thereby help to determine the most adequate treatment approach. There is no standard regarding the minimal number of LNs that should be removed in paraaortic lymphadenectomy. Women with undiagnosed positive paraaortic LNs (false negatives) due to a low LN count do not receive extended-field radiation therapy, which may lead to worse survival outcomes. The aim of this study is to confirm LN metastases as poor prognosis and to assess whether in cases of locally advanced CC with negative paraaortic LN status, the number of paraaortic LN laparoscopically removed carries a prognostic value.

METHODS

We analyzed 78 patients with locally advanced cervical cancer that underwent complete paraaortic lymphadenectomy.

RESULTS

Fifteen (19.2%) women had paraaortic LN metastases. The mean number of LN extracted was 11.1 (SD 7.5). Patients with paraaortic LN metastases presented a worse overall survival (127.1 months [95% CI 111.7-142.4] vs. 59.6 months [95% CI 31.2-87.9]; p<0.01). Nevertheless, there were no differences regarding disease-free survival. There were no prognostic differences according to the number of LNs resected in patients with negative lymphadenectomy.

CONCLUSIONS

Patients with locally advanced cervical cancer and paraaortic LN metastases present worse survival. In women with negative paraaortic LN, the number of LNs removed does not imply shorter survival.

Efficacy of a Fibrin Sealant (Tissucol Duo) for the Preventionof Lymphocele after Laparoscopic Pelvic Lymphadenectomy:A Randomized Controlled Trial

STUDY OBJECTIVE

To assess the efficacy of Tissucol Duo (Baxter AG, Vienna, Austria) fibrin sealant in decreasing the incidence of lymphocele (LC) after pelvic laparoscopic lymph node dissection using harmonic shears.

DESIGN

Randomized controlled trial (Canadian Task Force classification level I).

SETTING

Tertiary referral and educational center.

PATIENTS

Seventy-four patients randomized to the use of sealant per hemipelvis.

INTERVENTION

Fibrin sealant.

MEASUREMENTS AND MAIN RESULTS

After bilateral pelvic lymphadenectomy a fibrin sealant was used in 1 hemipelvis but not the other, applied in 41 patients (55.4%) to the left and 33 patients (44.6%) to the right hemipelvis. The primary outcome was the incidence of LC after surgery in symptomatic and asymptomatic patients. Imaging (ultrasound, computed tomography, and magnetic resonance) was performed to detect LC at 3, 6, and 12 months after surgery. Overall, 26 patients (35.1%) developed LC, and 4 were symptomatic (5.4%). Allowing patients to serve as their own treatment group and control, the hemipelvis treated with Tissucol Duo corresponding to the treatment group and that not treated to the control group, LCs were found in 17 (23%) and 14 (19%) cases, respectively, but the difference was not significant. The mean initial LC maximum diameter was 27.1 mm (standard deviaiotn, 35.2), and LCs tended to decrease in size during the first year to a mean of 8.7 mm.

CONCLUSION

Application of Tissucol Duo fibrin sealant after laparoscopic pelvic lymphadenectomy using ultrasonic shears does not decrease the occurrence of symptomatic or asymptomatic LC.

Risk factors and treatment of venous thromboembolism in perioperative patients with ovarian cancer in China

The aim of this study was to assess the major risk factors for venous thromboembolism (VTE) in Chinese patients with ovarian cancer and to explore optimal methods of prophylaxis and treatment.A retrospective analysis of patients from Qilu Hospital of Shandong University was conducted from January 1, 2014, to January 1, 2017. We analyzed 388 patients who underwent surgery with a final diagnosis of ovarian cancer, of whom 35 developed VTE. Risk factors for preoperative and postoperative VTE were investigated. Preoperative patients with VTE were treated with anticoagulant therapy; chemotherapy with carboplatin paclitaxel was administered for 2 or 3 courses before cytoreductive surgery.Fifteen patients were diagnosed with preoperative VTE and 20 with postoperative VTE. Eight of these 35 patients were also diagnosed with pulmonary embolism (PE), and 1 patient died. Univariate analysis showed differences in age, preoperative D-dimer value, platelet count, preoperative chemotherapy, operative time, and cardiovascular disease according to the presence or absence of VTE. In multivariate analysis, age 55 years and older, tumor diameter greater than 10 cm, preoperative platelet count greater than 300  × 10/L, and a D-dimer value greater than 0.5 μg/mL were independent risk factors for preoperative VTE, whereas a D-dimer value greater than 0.5 μg/mL and surgery time greater than 150 minutes were independent risk factors for postoperative VTE. Four preoperative patients with PE who underwent treatment with anticoagulant therapy and chemotherapy with carboplatin paclitaxel had disappearance of signs of PE and their ascites and mass sizes decreased substantially, leading to subsequent optimal cytoreduction.Preoperative screening and perioperative preventive measures should be taken in gynecological oncology surgery, especially when patients have risk factors identified in this study. For patients with ovarian cancer who have been diagnosed with thrombosis before surgery, adjuvant chemotherapy and anticoagulant drugs can be used to control the progression of thrombosis and cancer.

A collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: A randomized clinical trial

OBJECTIVE

To evaluate the efficacy of a collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies.

METHODS

In a multicenter, randomized, clinical trial, 164 women with pelvic lymphadenectomy were allocated either to bilateral pelvic application of two collagen-fibrin patches or no intervention. Main outcome was efficacy, defined as reduction of symptomatic lymphocele rate diagnosed within four weeks after surgery. Secondary outcomes were asymptomatic lymphoceles and subsequent interventions. Sample size was based on the assumption that application of a collagen-fibrin patch reduces the prevalence of symptomatic lymphoceles by at least 66%. The study was single-blinded, i.e., patients and primary outcome assessors, but not surgeons, were blinded to the treatment allocation.

RESULTS

A total of 75 women were randomized to the intervention and 89 to the control group. All women received the allocated intervention. In total, 42 (27.4%) lymphoceles and 8 (5.2%) symptomatic lymphoceles were observed. Symptomatic lymphoceles were observed in 5/68 (7.4%) women in the intervention group and 3/85 (3.5%) women in the control group (p = 0.47). Asymptomatic lymphoceles were observed in 16 (23.5%) women in the intervention group compared to 18 (21.2%) in the control group (p = 0.85). In a multivariate logistic regression model, no independent risk factor for the development of a symptomatic lymphocele was ascertained.

DISCUSSION

Intraoperative application of collagen-fibrin patches to the pelvic side walls does not reduce the incidence of symptomatic lymphoceles in women with gynecologic malignancies undergoing pelvic lymphadenectomy.

Venous Thromboembolism in Gynecological Malignancy

Objective

Venous thromboembolism (VTE) is a recognized complication of gynecological malignancy and represents a leading cause of morbidity and mortality in these patients. The review aimed to discuss the incidence, risk factors, and clinical presentation of VTE before examining the literature on the diagnosis, prevention, and management in the context of uterine, cervical, ovarian, and vulval cancers.

Methods/Materials

A literature search was performed using Ovid Medline and Embase with the following words: “gynecological malignancy,” “pelvic tumor,” “venous thromboembolism,” “deep vein thrombosis” and “pulmonary embolism.”

Results

The incidence of VTE in patients with gynecological malignancy ranged between 3% and 25% and was affected by several patient and tumor factors. Duplex ultrasonography is currently the first-line imaging modality for deep venous thrombosis with sensitivity and specificity of up to 95% and 100%, respectively. Low-molecular-weight heparin is currently the VTE prophylaxis and treatment of choice for patients with gynecological malignancy, although warfarin and unfractionated heparin play a role in selected circumstances. The relatively new direct oral anticoagulants including factor Xa inhibitors and direct thrombin inhibitors are increasingly being used, although further evaluations are required, particularly in cancer patients. Catheter-directed thrombolysis and percutaneous mechanical and surgical thrombectomy may have a role in treating patients with severe symptomatic iliocaval or iliofemoral deep venous thrombosis. Overall, VTE is a poor prognosis marker in patients with gynecological malignancy.

Conclusions

Gynecological malignancy–associated VTE is associated with significant morbidity, contributing to a large number of life years lost. Although promising new therapies are emerging, a 2-pronged approach is required to simultaneously target cancer-specific management and predict early on those who are likely to be affected. In the meantime, clinicians should continue to combine current guidelines with a multidisciplinary team approach to ensure that these complex patients receive the best evidence-based and compassionate care.

A collagen-fibrin patch (Tachosil®) for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: a randomized clinical trial

Background

Lymphoceles are a common complication after pelvic lymphadenectomy in women with gynecologic malignancies. Although typically asymptomatic, lymphoceles can superinfect requiring medical or surgical intervention. A single center randomized controlled trial provided first evidence, that a collagen-fibrin patch (Tachosil®) is effective in the prevention of symptomatic lymphoceles after pelvic lymphadenectomy.

Methods/Design

We will perform a multicentre, blinded, randomized, controlled trial comprising 140 women with gynecologic malignancies undergoing pelvic lymphadenectomy. Women will be randomly allocated to Tachosil® application or no application. Primary outcome is efficacy, defined as lymphocele CTCAE 4.03 grade ≥2 within four weeks after surgery. Secondary outcomes are asymptomatic lymphocele verified by ultrasound, medical or surgical intervention. Assuming a two-sided 5% significance level, a power of 80%, and a drop out rate of 10%, a sample size of 68 patients per group was calculated to detect a 66% absolute decrease in symptomatic lymphoceles.

Discussion

We aim to provide further evidence for the efficacy of a collagen-fibrin patch in the prevention of symptomatic lymphoceles in women with gynecological malignancies undergoing pelvic lymphadenectomy.

Trial registration

This study is registered at ClinicalTrials.gov (NCT01470677, protocol ID: TACHO-1). This study is registered at the EudraCT database (EudraCT number: 2011-003115-34).

Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device

OBJECTIVE

A number of new techniques have been developed to prevent lymphocele formation after pelvic lymphadenectomy in gynecologic cancers. We assessed whether the electrothermal bipolar vessel sealing device (EBVSD) could decrease the incidence of postoperative lymphocele secondary to pelvic lymphadenectomy.

METHODS

A total of 321 patients with gynecologic cancer underwent pelvic lymphadenectomy from 2005 to 2011. Pelvic lymphadenectomy without EBVSD was performed in 134 patients, and pelvic lymphadenectomy with EBVSD was performed in 187 patients. We retrospectively compared the incidence of lymphocele and symptoms between both groups.

RESULTS

Four to 8 weeks after operation, 108 cases of lymphocele (34%) were detected by computed tomography scan examination. The incidence of lymphocele after pelvic lymphadenectomy was 56% (75/134) in the tie ligation group, and 18% (33/187) in the EBVSD group. We found a statistically significant difference in the incidence of lymphocele between both groups (p<0.01). To detect the independent risk factor for lymphocele development, we performed multivariate analysis with logistic regression for three variables (device, number of dissected lymph nodes, and operation time). Among these variables, we found a significant difference (p<0.001) for only one device.

CONCLUSION

Use of the EBVSD during gynecological cancer operation is useful for preventing the development of lymphocele secondary to pelvic lymphadenectomy.

Feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy in gynecologic malignancies

OBJECTIVE

The aim of this study is to evaluate the feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy (LEPL) in gynecologic malignancies.

METHODS

Twenty-nine women with cervical, ovarian or endometrial cancer underwent laparoscopic extraperitoneal pelvic lymphadenectomy between July 2008 and December 2010. The operating time, nodal yield, blood loss and complications were recorded.

RESULTS

The number of patients with cervical, ovarian and endometrial carcinoma was 14, 3 and 12, respectively. The median age of patients was 48.9±12.6 years. The median body mass index was 25.6±4.8. Conversion to the transperitoneal laparoscopic approach was necessary in 6 patients for peritoneal tears causing CO(2) gas leakage. Among the remaining 23 patients, the median operating time for laparoscopic extraperitoneal pelvic lymphadenectomy was 69 min (range 50-126 min), and the median estimated blood loss was 20 ml (range 5-105 ml). The median total number of resected nodes was 26 (range 14-42), and complications related to the procedure were rare.

CONCLUSIONS

Laparoscopic extraperitoneal pelvic lymphadenectomy is a feasible and safe procedure. It can be used in gynecologic malignancies.

A randomized study comparing the use of the Ligaclip with bipolar energy to prevent lymphocele during laparoscopic pelvic lymphadenectomy for gynecologic cancer

OBJECTIVE

This prospective randomized pilot study compared the use of the Ligaclip (Ethicon Endo-Surgery, Cincinnati, OH) with bipolar coagulation in preventing lymphoceles after laparoscopic pelvic lymphadenectomy for gynecologic cancer.

STUDY DESIGN

Thirty patients with gynecologic malignancy, who had laparoscopic pelvic lymphadenectomy were randomly assigned for lymphadenectomy in 1 side of the pelvis using the Ligaclip, whereas, in the other side, the bipolar coagulation to seal lymphatic vessels was used.

RESULTS

At ultrasound examination, we detected lymphocele in 10 patients (33%). Lymphocele developed in 9 (30%) patients on the side where laparoscopic pelvic lymphadenectomy was perfomed using bipolar coagulation, and in 1 (3.3%) patient on the side where laparoscopic pelvic lymphadenectomy was performed using the Ligaclip. Univariate analysis revealed that the Ligaclip's use compared with electrocoagulation in the laparoscopic pelvic lymphadenectomy is an independent predictive factor for development of lymphocele (P = .006).

CONCLUSION

This study demonstrates that the use of the Ligaclip to close lymphatic vessels may reduce the incidence of lymphoceles in patients undergoing laparoscopic pelvic lymphadenectomy.

Lymphadenectomy for patients with cervical cancer: is it of value?

INTRODUCTION

Discovery of positive lymph nodes (LNs) in patients with cervix cancer is important prognostically, may direct adjuvant therapy, and may have therapeutic benefit. The purpose of this Surveillance Epidemiology and End Results (SEER) analysis was to assess the value of lymphadenectomy (LND) in patients with cervical cancer.

METHODS

The 17-registry SEER database was searched for patients treated for cervical cancer between 1988 and 1998. Observed survival (OS) and expected survival (ES) were reported with a minimum of 5-year follow-up. Chi-square analysis and log-rank test were used to compare OS and ES.

RESULTS

Between 1988 and 1998, 4,059 of 12,882 patients underwent LND for cervical cancer and were registered. By stage, 2,653 of 7,621 stage I, 341 of 2,042 stage II, 814 of 1,986 stage III, 251 of 1,233 stage IV, and 28 of 226 stage IVA patients underwent LND. Of these, 778 stage III and 210 stage IV patients had a +LN. Patients who underwent LND had improved OS (P = 0.001). OS was significantly increased for each stage after LND. OS increased based on number of nodes resected. OS increased up to 15 nodes resected (P = 0.01).

CONCLUSION

This SEER analysis of 12,882 patients suggests that LND benefited patients with cervical cancer and OS was improved.

Pelvic and aortic lymphadenectomy in cervical cancer: the standardization of surgical procedure and its clinical impact

Cervical cancer ranks as the second most frequent cancer in women in the world, and nodal metastasis seems to be the first step of tumor spread in most cases. Since lymph node involvement is a major prognostic factor in cervical carcinoma, lymphatic spread of cervical cancer has been one of the most studied surgical topics in gynecologic oncology. Traditionally, lymph nodes stations have been accurately analyzed, improving surgical techniques of nodal dissection, which have been more and more intensive during years with the aim of improving survival. Oppositely, on the basis of recent acquisitions in cancer immunology and new anti-cancer immunotherapies and vaccines, the importance of lymph nodes has been recently reconsidered. Unfortunately, lymph node status is still difficult to be assessed pre-operatively with a high level of accuracy, and intra-operatively by sentinel node techniques, which remain inadequate for many aspects according to several gynecologic oncologists. The absence of definitive evidence of survival advantage given by extensive lymphadenectomy in all cervical cancer cases indicates that nodal dissection should be performed on the objective risk of node metastasis in each case. To date, the mainstay of detecting lymph node metastasis is still the histologic evaluation, therefore a proper resection of mostly involved lymph nodes remains a crucial surgical step when treating cervical cancer.

The outcome of laparoscopic radical hysterectomy and lymphadenectomy for cervical cancer: a prospective analysis of 295 patients

OBJECTIVES

Cervical carcinoma is likely to become one of the most important indications for laparoscopic radical surgery. The laparoscopic technique combines the benefits of a minimally invasive approach with established surgical principles. In our institution, the laparoscopic radical hysterectomy and transperitoneal approach for lymphadenectomy have become the standard techniques for invasive cervical cancer. We report the indications, techniques, results, and oncological outcome in a single center experience.

METHODS

Between February 2001 and June 2007 we performed laparoscopic radical hysterectomies for cervical cancer in 295 patients. Their initial techniques, operation data, complications, postoperative course, oncological outcome, and survival were evaluated.

RESULTS

Out of 295 procedures, 290 were successful. Para-aortic lymphadenectomy was performed in 156 patients (52.9%), and pelvic lymphadenectomy was performed in all 295 patients. The median blood loss was 230 mL (range, 50-1200 mL). The mean operation time was 162 min (range, 110-350), which included the learning curves of 3 surgeons. In 5 cases (1.7%), conversion to open surgery was necessary due to bleeding (3 cases), bowel injury (1 case), and hypercapnia (1 case). Other major intraoperative injuries occurred in 12 patients (4.1%). Positive lymph nodes were detected in 80 cases (27.1%), lymphovascular space invasion in 54 cases (18.3%), and surgical margins were negative for tumor in all patients. The mean hospital stay was 10.3 days. Postoperative complications occurred in 10.8% patients, ureterovaginal fistula in 5 cases, vesicovaginal fistula in 4, ureterostenosis in 3 cases, deep venous thrombosis in 9 cases, lymphocyst in 4 cases, lymphedema in 5 cases, and 1 case with trocar insertion site metastasis. Other medical problems included 47 cases (15.9%) of bladder dysfunction and 62 cases (21.0%) of rectum dysfunction or constipation. The median follow-up was 36.45 months (range, 8-76 months). Recurrences or metastasis occurred in 48 patients (16.3%). Of these patients, 43 (14.6%) have died of their disease, and 5 (1.7%) are alive with disease. The overall disease-free survival was 95.2% for Ia, 96.2% for Ib, 84.5% for IIa, 79.4% for IIb, 66.7% for IIIa, and 60.0% for IIIb.

CONCLUSION

Laparoscopic radical hysterectomy is a routine, effective treatment for patients with Ia2-IIb cervical carcinoma. With more experience it is envisaged that IIb stage patients can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available, our follow-up data for up to 76 months confirm the effectiveness of laparoscopic radical hysterectomy in terms of surgical principles and oncological outcome.

Utility of parametrectomy for early stage cervical cancer treated with radical hysterectomy

BACKGROUND

Removal of the parametrial soft tissue is recommended for patients with cervical cancer undergoing radical hysterectomy. Parametrectomy results in significant morbidity. The objective of the study was to determine factors predictive of parametrial tumor spread and to define a subset of patients at low risk for parametrial disease.

METHODS

Patients with invasive cervical cancer who underwent radical hysterectomy from 1989-2005 were examined. Analysis was performed to determine factors associated with parametrial tumor spread. Survival estimates were determined using the Kaplan-Meier method.

RESULTS

A total of 594 patients were identified. Parametrial metastases were documented in 64 (10.8%). Factors associated with parametrial disease were: histology, advanced grade, deep cervical invasion, lymphovascular space invasion (LVSI), large tumor size, advanced stage, uterine or vaginal involvement, and pelvic or para-aortic lymph node metastases (P < .0001 for each). Parametrial metastases were associated with increased risk of recurrence and decreased disease-free and overall survivals (P < .0001). A subgroup analysis was performed to identify patients at low risk for parametrial spread. In pelvic node-negative women parametrial disease was noted in 6.0% (30/498) compared with 47.9% (34 of 71) of those with positive pelvic nodes (P < .0001). If further stratified to women with negative nodes, no LVSI, and tumors < 2 cm, the incidence of parametrial disease was only 0.4%.

CONCLUSIONS

Parametrial spread is a strong predictor of recurrence and decreased survival. Parametrial invasion is rare in patients with small tumors, no LVSI, and negative pelvic nodes (no poor prognostic factors). Further study is warranted to determine the feasibility of omitting parametrectomy in these low-risk patients.